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Aim: To analyze early and mid-term outcomes of the Bentall operation. Methods: Two hundred and seventeen patients (mean age 65.6 ± 15.9 years, males/females 172/45) underwent Bentall operation in a 7-year period (January 2015–December 2021), on average, 30 Bentall operations occurred per year, using biological (n = 104) or mechanical (n = 113) valved conduits for the treatment of ascending aorta–aortic root aneurysms. Associate procedures were performed in 58 patients (26.7%); coronary artery bypass grafting (CABG) in 35 (16%). Mean follow-up was 55.2 ± 24 (median 60.2) months. Cox model analysis was used to assess risk factors, Kaplan–Meier and log-rank tests were used to assess different survival rates. Results: Operative mortality was 1.38%. At 7 years, survival, freedom from cardiac death, and event-free survival were 93% ± 2%, 99% ± 1%, and 81% ± 5%. NYHA class (p < 0.0001), trans-aortic valve mean (p < 0.0001) and maximum (p < 0.000) gradients, left ventricular hypertrophy (p < 0.05), and pulmonary arterial pressure (p = 0.002) significantly improved vs. preoperative values. Concomitant CABG during Bentall operation independently affected late outcomes (HR 1.9–2.3; p-values < 0.05). Late survival was affected by concomitant CABG (84% ± 8% vs. 95% ± 2%, p = 0.04), preoperative myocardial infarction (91% ± 9% vs. 97% ± 2%, p = 0.02), and biological vs. mechanical prostheses valved conduits (91% ± 9% vs. 95% ± 3%, p = 0.02). Event-free survival also was affected by concomitant CABG (62% ± 14% vs. 85% ± 5%, p = 0.005) and biological prostheses (78% ± 8% vs. 84% ± 6%, p = 0.06). Freedom from endocarditis–redo operation was 83% ± 9% for biological prostheses vs. 89% ± 6% for mechanical prostheses (p = 0.49). Conclusions: Low rates of operative mortality and late complications make Bentall operation the gold standard for the treatment of ascending aorta–aortic root aneurysms. Coronary ischemic disease affects late outcomes. Biological prostheses should be preferred for the elderly.

Postoperative atrial fibrillation (POAF) is the most common arrhythmia after cardiac surgery in conventional extracorporeal circulation (CECC), with an incidence of 15–50%. The POAF pathophysiology is not known, and no blood biomarkers exist. However, an association between increased ferritin levels and increased AF risk, has been demonstrated. Based on such evidence, here, we evaluated the effectiveness of ferritin and other haematological parameters as POAF risk biomarkers in patients subjected to cardiac surgery. We enrolled 105 patients (mean age = 70.1 ± 7.1 years; 70 men and 35 females) with diverse heart pathologies and who were subjected to cardiothoracic surgery. Their blood samples were collected and used to determine hematological parameters. Electrocardiographic and echocardiographic parameters were also evaluated. The data obtained demonstrated significantly higher levels of serum ferritin, red cell distribution width (RDW), and platelets (PLTs) in POAF patients. However, the serum ferritin resulted to be the independent factor associated with the onset POAF risk. Thus, we detected the ferritin cut-off value, which, when ≥148.5 ng/mL, identifies the subjects at the highest POAF risk, and with abnormal ECG atrial parameters, such as PW indices, and altered structural heart disease variables. Serum ferritin, RDW, and PTLs represent predictive biomarkers of POAF after cardiothoracic surgery in CECC; particularly, serum ferritin combined with anormal PW indices and structural heart disease variables can represent an optimal tool for predicting not only POAF, but also the eventual stroke onset.

The pathobiology of ascending aorta aneurysms (AAA) onset and progression is not well understood and only partially characterized. AAA are also complicated in case of bicuspid aorta valve (BAV) anatomy. There is emerging evidence about the crucial role of endothelium-related pathways, which show in AAA an altered expression and function. Here, we examined the involvement of ERG-related pathways in the differential progression of disease in aortic tissues from patients having a BAV or tricuspid aorta valve (TAV) with or without AAA. Our findings identified ERG as a novel endothelial-specific regulator of TGF-β-SMAD, Notch, and NO pathways, by modulating a differential fibrotic or calcified AAA progression in BAV and TAV aortas. We provided evidence that calcification is correlated to different ERG expression (as gene and protein), which appears to be under control of Notch signaling. The latter, when increased, associated with an early calcification in aortas with BAV valve and aneurysmatic, was demonstrated to favor the progression versus severe complications, i.e., dissection or rupture. In TAV aneurysmatic aortas, ERG appeared to modulate fibrosis. Therefore, we proposed that ERG may represent a sensitive tissue biomarker to monitor AAA progression and a target to develop therapeutic strategies and influence surgical procedures.

(1) Background: We sought to analyze and compare the outcomes in terms of early and late mortality and freedom from a redo operation in patients undergoing surgical treatment for a type A acute aortic dissection in relation to the initial surgical treatment strategy, i.e., proximal or distal extension of the aortic segment resection, compared with isolated resection of the supracoronary ascending aorta. (2) Methods: This is a retrospective study in which we included 269 patients who underwent operations for a type A acute aortic dissection in the Department of Cardiac Surgery of Tor Vergata University from May 2006 to May 2016. The patients were grouped according to the extent of the performed surgical treatment: isolated replacement of the supracoronary ascending aorta (NE, no extension), replacement of the aortic root (PE, proximal extension), replacement of the aortic arch (DE, distal extension), and both (BE, bilateral extension). The analyzed variables were in-hospital mortality, postoperative complications (incidence of neurological damage, renal failure and need for prolonged intubation), late mortality and need for a redo operation. (3) Results: Unilateral cerebral perfusion was performed in 49.3% of the patients, and bilateral perfusion—in 50.6%. The overall in-hospital mortality was 31.97%. In the multivariate analysis, advanced age, cardiopulmonary bypass time and preoperative orotracheal intubation were independent predictors of in-hospital mortality. In the population of patients who survived the surgery, the probability of survival at 92 months was 70 ± 5%, the probability of freedom from a redo operation was 71.5 ± 5%, the probability of freedom from the combined end-point death and a redo operation was 50 ± 5%. The re-intervention rate in the general population was 16.9%. The overall probability of freedom from re-intervention was higher in patients undergoing aortic root replacement, although not reaching a level of statistical significance. Patients who underwent aortic arch treatment showed reduced survival. (4) Conclusions: In the treatment of type A acute aortic dissection, all the surgical strategies adopted were associated with satisfactory long-term survival. In the group of patients in which the aortic root had not been replaced, we observed reduced event-free survival.

Aim: We evaluated the short- and mid-term results of mitral valve replacement (MVR) and mitral valve repair (MV-repair). Methods: In total, 168 patients (mean age 67 ± 11 years) underwent MVR (n = 104) and MV-repair (n = 64). To treat posterior leaflet disease, MV-repair techniques included triangular or quadrangular resection (n = 38), P1-P2 plication (n = 4), side-to side P1-P2 (n = 1), posterior-medial commissure-plasty (n = 1), and annuloplasty (n = 20). A prosthetic ring was implanted in all patients. In the presence of degenerative disease involving the anterior leaflet, extensive myxomatous and/or prolapsing pathology of the entire valve, and/or rheumatic and endocarditis degeneration, surgical orientation was to perform MVR directly. When possible, the sub-valvular apparatus with its papillary muscle was partially preserved. The mean follow-up was 38 ± 22 months. Results: Operative mortality (0.96% vs. 1.56%) and six-year survival (94% vs. 100%) were similar in MVR and MV-repair. The only independent predictor of late survival was advanced age at the operation (79.2 years vs. 66.4 years; P = 0.012). Freedom from redo-operation was 100%. Partial preservation of the sub-valvular apparatus with its papillary muscle during MVR allowed postoperatively a better left ventricular function with similar values achieved with MV-repair (P = 0.05), and it was a protective factor against the development of left ventricular dysfunction during follow-up (P = 0.01). Conclusion: MVR and MV-repair are associated with satisfactory results in the short and medium term. MV-repair to treat posterior leaflet disease is associated with a stable and long-lasting result; MVR allows equally satisfactory results in the presence of more extensive and more complex mitral valve disease. Partial preservation of the sub-valvular apparatus favors a better left ventricular systolic function.

Introduction Dual antiplatelet therapy reduces the risk of cardiovascular death, myocardial infarction and recurrence of adverse ischemic events in patients affected by acute coronary syndromes, but in patients urgently needing coronary artery surgery it can increase the risk of severe perioperative bleeding complications. Aim We evaluated the impact of dual antiplatelet therapy (DAPT) based on acetylsalicylic acid plus clopidogrel or ticagrelor in patients undergoing coronary artery bypass grafting (CABG). Material and methods Three hundred and thirty-three patients underwent coronary artery bypass grafting with DAPT discontinuation > 72 hours or 3–4 days (group A, n = 159), 48–72 hours or 2–3 days (group B, n = 126), < 24 hours or 0–1 day (group C, n = 24) prior to CABG. Results Operative mortality was 1.87% (group A), 0.79% (group B), absent (group C). The incidence of mediastinal re-exploration was 1.25% or 2 patients (group A), 1.59% or 2 patients (group B), 8.33% or 4 patients (group C) (p = 0.01). Group C showed postoperatively a greater incidence of a blood loss greater than 500 ml at 6 hours and a blood loss from chest tube drainages significantly higher at 6 and 24 hours (p < 0.01). Multivariate analysis showed that ongoing ticagrelor intake in group C (HR = 42.4; p = 0.02) and group C (HR = 6.9; p = 0.04) were the only independent predictors of surgical re-exploration. In group C, surgical re-exploration was 2.56% or 1/39 patients taking clopidogrel, 33.3% or 3/9 patients taking ticagrelor (p = 0.002). Conclusions Dual antiplatelet therapy ongoing until 1 day or 24 hours before CABG showed a significantly increased risk of bleeding complications in comparison with its discontinuation at 2–3 and > 3–4 days before, respectively. Major blood loss and surgical re-exploration were not associated with increased risk of operative all-cause or bleeding-related mortality. As expected, taking ticagrelor compared with clopidogrel in the short interval confers a higher risk of bleeding complications.

BACKGROUND: Minimally invasive approach through a right mini-thoracotomy is a world-wide used procedure for mitral valve surgery. We performed a retrospective analysis based on our center experience in order to propose an effective, safe and reproducible method using an intra-aortic occlusion device. METHODS: This is a retrospective analysis on 48 consecutive patients undergoing mitral valve surgery through a right anterolateral mini-thoracotomy in our center. An intra-aortic occlusion device was used for aortic clamping and cardioplegia delivery. Simultaneous multi-plane three-dimensional echocardiography imaging was acquired to detect the venous cannulas position, the intra-aortic device location in the ascending aorta, the balloon inflation, the complete occlusion of the aorta, the cardioplegia delivery, the origin and the blood flow in the right coronary artery. Aortic root pressure was measured by the tip of the intra-aortic occlusion device. A bilateral upper extremity invasive arterial pressure monitoring was detected. Neuromonitoring was performed through bilateral cerebral oximetry. RESULTS: The analysis has shown no aortic dissection, neurological damage type 1 and myocardial ischemia in the study population. In 3 cases a distal displacement of the intra-aortic occlusion device was promptly detected by the combined use of echocardiographic imaging and by a drop of the right cerebral oximetry saturation and of the right radial artery pressure. CONCLUSIONS: The combined use of transesophageal simultaneous multi-plane three- dimensional echocardiography imaging, bilateral upper extremity invasive arterial pressure monitoring, aortic root pressure and cerebral oximetry is an effective, safe and reproducible method in patients undergoing minimally invasive valve surgery using an intra-aortic occlusion device.

Introduction Emergent surgical repair of DeBakey type I and II acute aortic dissection represents the standard of care to prevent lethal complications. Aim Evaluation of the effect of extension of aortic dissection (AAD) according to DeBakey classification, type I and II AAD, and the relationship with preoperative peripheral and myocardial malperfusion on early outcome and the mid-term follow-up period. Material and methods A total of 135 patients who underwent AAD surgery between January 2015 and October 2019 were analysed. Results In total 103 patients were affected by DeBakey type I AAD and 32 by DeBakey type II; 56 patients preoperatively showed peripheral, cardiac malperfusion, or both. Intra-operative mortality was 11%. Postoperative peripheral, cardiac malperfusion, and intraoperative and postoperative mortality were lower for type II AAD. The protective factor for intra- and postoperative 60-day mortality was type II AAD (RR = 0.03, p = 0.001); independent predictors were hypertension, and preoperative cardiac and renal-visceral malperfusion. At 5 years the overall survival was 74 ±6.9%. Independent predictors of reduced survival were major extension of type I AAD (RR = 5.37, p < 0.05) and preoperative cardiac malperfusion (RR = 5.78, p < 0.05). Five-year freedom from cardiac death, redo surgical operation, and new vascular procedures on the thoracic and abdominal aorta was 92 ±5.7%, 99 ±1.2%, and 81 ±7.2%, respectively. Extension of DeBakey type I AAD into the thoracic-abdominal aorta segment was also a predictor of the need for new vascular procedures (RR = 1.66, p = 0.05). Conclusions A more favourable anatomy of DeBakey type II AAD is associated with better early and late outcomes after aortic repair. This is due to a lower incidence of peripheral and cardiac malperfusion.

Study objective: To evaluate the long-term outcomes of clampless off-pump coronary artery bypass grafting (C-OPCAB) compared with conventional on-pump double clamping coronary artery bypass grafting (C-CABG). Methods: From October 2006 to December 2011, 366 patients underwent isolated coronary artery bypass grafting. After propensity score matching of preoperative variables, 143 pairs were selected who received C-OPCAB with the use of device-assisted PAS-Port proximal venous graft anastomoses or C-CABG, performed by the same surgeon experienced in both techniques. Data of the two groups of patients were retrospectively analyzed up to 14 years of follow-up. Results: As compared with C-OPCAB, in the C-CABG patients, the performed number of grafts per patient was higher (2.9 ± 0.5 vs. 2.6 ± 0.6, p-value 0.0001). At 14 years, overall survival, including in-hospital death, was 64 ± 4.7% for the C-OPCAB vs. 55 ± 5.5% for the C-CABG, freedom from overall MACCEs 51 ± 6.2% vs. 41 ± 7.7%, and from late cardiac death 94 ± 2.4% vs. 96 ± 2.2% (p-value not significant, for all comparisons). No significant statistical differences were observed in the actual rates of adverse events during follow-up. Independent predictors of survival were advanced age at operation (p-value 0.001) and a lower mean value of preoperative left ventricular ejection fraction (p-value 0.015). Conclusions: Our single-center study analysis suggests that clampless OPCAB using device-assisted proximal anastomoses proved to be not inferior to double-clamping CABG in the long-term follow-up, provided that involved surgeons are familiar with both techniques. These conclusions are supported by a large and long-term follow-up period, eliminating potential bias, i.e., by means of the propensity score matching and analyzing single-surgeon experience.

Thoracic aortic aneurysm represents a deadly condition, particularly when it evolves into rupture and dissection. Proper surgical timing is the key to positively influencing the survival of patients with this pathology. According to the most recent guidelines, ascending aorta size ≥ 55 mm and a rate of growth ≥ 0.5 cm per year are the most important factors for surgical indication. Nevertheless, a lot of evidence show that aortic ruptures and dissections might occur also in small size ascending aorta. In this review, we sought to analyze a new biological and morphological network behind the aortic diameter that need to be considered in order to identify the portion of patients with thoracic aortic aneurysm who are at increased risk of aortic complications, despite current aortic guidelines not advising surgical intervention in this group

Background We sought to investigate and compare biomechanical properties and histomorphometric findings of thoracic ascending aorta aneurysm (TAA) tissue from patients with bicuspid aortic valve (BAV) and tricuspid aortic valve (TAV) in order to clarify mechanisms underlying differences in the clinical course. Methods Circumferential sections of TAA tissue in patients with BAV (BAV-TAA) and TAV (TAV-TAA) were obtained during surgery and used for biomechanical tests and histomorphometrical analysis. Results In BAV-TAA, we observed biomechanical higher peak stress and lower Young modulus values compared with TAV-TAA wall. The right lateral longitudinal region seemed to be the most fragile zone of the TAA wall. Mechanical stress-induced rupture of BAV-TAA tissue was sudden and uniform in all aortic wall layers, whereas a gradual and progressive aortic wall breakage was described in TAV-TAA. Histomorphometric analysis revealed higher amount of collagen but not elastin in BAV-TAA tunica media. Conclusions The higher deformability of BAV-TAA tissue supports the hypothesis that increased wall shear stress doesn't explain the increased risk of sudden onset of rupture and dissection; other mechanisms, likely related to alteration of specific genetic pathways and epigenetic signals, could be investigated to explain differences in aortic dissection and rupture in BAV patients.

Frailty is the major expression of accelerated aging and describes a decreased resistance to stressors, and consequently an increased vulnerability to additional diseases in elderly people. The vascular aging related to frail phenotype reflects the high susceptibility for cardiovascular diseases and negative postoperative outcomes after cardiac surgery. Sarcopenia can be considered a biological substrate of physical frailty. Malnutrition and physical inactivity play a key role in the pathogenesis of sarcopenia. We searched on Medline (PubMed) and Scopus for relevant literature published over the last 10 years and analyzed the strong correlation between frailty, sarcopenia and cardiovascular diseases in elderly patient. In our opinion, a right food intake and moderate intensity resistance exercise are mandatory in order to better prepare patients undergoing cardiac operation.